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INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,252137,AND 254,9 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN U.ST'OPERATING PERMIT.
<br /> 1, One FORM"°A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES,
<br /> 2. SUBMIT ONLY ONE(1)FORM"A"for a Facility/Site,regardless of the number of tanks located at the site.
<br /> 3. `Phis form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR,
<br /> 4. Please type or print clearly all requested information.
<br /> 5. Use a hard point writing instrument,you are making 3 copies.
<br /> 6. Tank owner trust submit a facility plat plan to the local agency as part of the application showing the location of the USTs with respect to
<br /> buildings and landmarks[Section 2711(a)(P),CCR].
<br /> 7, Tank owner mustsubmit documentation showing compliance with state financial responsibility requirements to the local agency as part of the
<br /> application for petroleum USTs[,section 2711(a)(11),CCR[.
<br /> TOP OF FORM:"MARK ONLY ONE ITEM"
<br /> Mark an(X)in the box next to the item that best describes the mason the form is being completed.
<br /> 1. FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> I, Record name and address(physical location)of the underground tank(s).
<br /> NOTE: Address MUST have a valid physical location including city,state,and zip code,
<br /> P.O.BOX NUMBERS ARE NOT ACCEPTABLE,
<br /> ,
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number must have an area code. If the night number is the same,write"SAME"in prosper locatioan.
<br /> 3. Check the appropriate box forTYPE OF BUSINESS OWNERSHIP(ex,CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate box for TYPE OF BUSINESS.
<br /> 5. If Facility/Site is located within an Indian reservation or other Indian trust lands.check the box marked"YES".
<br /> 6. Indicate the NUMBER of TANKS at this SITE.
<br /> 7. Record the E,P.A.ID#or write"NONE"in the space provided,
<br /> 11. PROPERTY OWNER IINTORMATION s&ADDRESS(MUST BE COMPLETED)
<br /> Complete all°stems in this section,unless all items are the same as SECTION 1;If the same,wrote"'SAME'AS SITE"across this section. Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box. r-1
<br /> Ill.TANK OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are the same as SECTION 1;if the same,write"SAME AS SITE"across this section. Be sure
<br /> to check TANK OWNERS TYPE,box.
<br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER.(MUST BE COMPLETED.SEE ARTICLE 5,CHAPTER 6.75,
<br /> DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE,)
<br /> Enter your Board of Equalization(BOF)UST steerage fee account number which is required before your permit application can be processed,
<br /> Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting the per gallon fee clue on the number of
<br /> gallons placed in your USTs. The BOE will code persons exemp4 fro€n paying the storage fee so returns will not be sent. If you do not have an
<br /> account number with the BOE or if you have any questions regarding the fee or exemptions,please call the BOE at 916-322-9669 or write to the
<br /> BOB.at the following address Board of Equalization,Fuel Taxe;Division,P,O,Box 942574,Sacramento,CA 44279.0001,
<br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY(MUST BE COMPLETED FOR PETROLEUM UST,,ONLY,SEE SECTIONS 2711 (a)(I 1)
<br /> OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.)
<br /> Identify the methods)used by the owner and/or operator,in meeting the Federal and Stats;financial responsibility requirements,USTs owned by
<br /> any Federal or State agency as well as non-petroleums UST's are exempt from this requirement,
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS,
<br /> TANK.OWNER OR AUTHOR17FD REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDICATED, (SLE SECTIONS 2711
<br /> (a)(I3)OF TITLE 23 CHAPTER 16,CALIFORNIA CODE OF RFGUL,ATION&I
<br /> INSTRUCTION FOR THE LOCAL.AGENCIES
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)227-4303. The facility number may
<br /> be assigned by the local agency;however,this number€na€st be numerical and cannot contain any alphabetical characters. If the local agency
<br /> prefers the State Board to assign the facility number,please/cave it blank.
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY TETE ACCURACY OF THE
<br /> INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. THE LOCAL.
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE"LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL
<br /> AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED BY THE TANK
<br /> PWNER.
<br /> 6.195
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